Why dealing with CMS regarding conditional payments is about to get much better.
We are thrilled to announce that Congress has passed the Smart Act. This legislation is a victory for claimants, insurance companies, business interests, and the US taxpayer. It will go a long way towards fixing the conditional payment problem.
By way of background, CMS will make payments for medical treatment related to a work injury even though another party may be responsible under Michigan law. These conditional payments must be paid back if an individual later receives a settlement or award from workers compensation.
Under the current system, CMS would not provide a final demand until after a workers compensation case was settled. This means that Medicare beneficiaries and other stakeholders had to guess as to the lien amount.
Resolving a workers compensation case became extremely difficult because nobody really knew how much had to be paid back. The process was slow, inaccurate, and provided no certainty to claimants.
Everyone agrees that Medicare should be paid back for conditional payments. The problem has always been how CMS implemented its recovery program. These changes will help make the process much better. It will also result in faster and more streamlined payments to the Medicare Trust Fund.
Fixing the recovery process
CMS will now have to provide the amount of conditional payments prior to settlement of a workers compensation case. This information will be provided via a website and can be relied upon as the final demand amount.
A right of appeal is established so that parties can challenge a determination of conditional payments.
CMS will be subjected to a 3 year statute of limitations to enforce its right to reimbursement for conditional payments.
Secondary payer compliance
Unfortunately, the recovery process will continue to be overly complex. Medicare beneficiaries and other stakeholders will need to notify CMS 120 days before the expected date of a settlement. Parties must also complete the settlement within 3 business days from the time the lien amount is electronically accessed.
Additionally, there is no provision that requires CMS to take a lesser amount in a disputed case. CMS needs to take an active role in compromising its lien when the facts of the case show an unlikelihood of recovery at trial.
Call (855) 221-2667 to speak with one of our Michigan workers compensation lawyers. There is no fee to review your case.
– Alex Berman is the founder of Michigan Workers Comp Lawyers. Hes been representing injured and disabled workers exclusively for more than 35 years. Alex has helped countless people obtain workers compensation benefits and never charges a fee to evaluate a case.
The Strengthening Medicare and Repaying Taxpayers (SMART) Act H.R. 1063, now renumbered as H.R. 1845